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Arruda Correia ML, Peixoto Filho FM, Gomes Júnior SC, de Jesus GR. Effects of osteopathic manipulative treatment on maternal-fetal hemodynamics in third trimester pregnant women: A prospective study. PLoS One 2024; 19:e0300514. [PMID: 38507460 PMCID: PMC10954147 DOI: 10.1371/journal.pone.0300514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/24/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE To evaluate the maternal-fetal hemodynamic effects after osteopathic manipulative treatment by measuring vital signs and Doppler velocimetry in third-trimester pregnant women. MATERIALS AND METHODS This is a prospective study with pregnant women undergoing outpatient follow-up and hospitalized in a ward at Instituto Fernandes Figueira/Fiocruz, between August 2021 to August 2022, during the SARS-CoV-2 pandemic. This study was registered in REBEC under Register Number RBR-9q7kvg and approved by the ethics committee under number 32216620.0.0000.5269. The study population was composed of 51 pregnant women between 28 and 40 weeks of gestation, over 18 years of age, allocated in a single group. Pregnancies with multiple fetuses, malformations, premature rupture of the membrane, and active labor were excluded. The procedures evaluated maternal-fetal hemodynamics using three consecutive measures of ultrasound examination with Doppler velocimetry, and three maternal vital signs measured by an electronic blood pressure monitor. RESULTS Most vital signs changed after osteopathic treatment. However, only the systolic blood pressure (109.92 ±14.42 to 110.71±12.8, p = 0.033), diastolic blood pressure (79.8±11.54 to 77.57±9.44, p = 0.018) and heart rate (87.59±11.93 to 81.12±10.26, p = 0.000) in the sitting position, systolic blood pressure (110.75±13.26 to 108.59±13.07; p = 0.034) in the supine, and heart rate (83.22±11.29 to 80.39±11.0; p = 0.013) in left lateral decubitus reached statistical significance. The oximetry measures (98.55±0.64 to 98.67±0.68; p = 0.098) stayed stable during all three positions. All artery values remained stable after treatment, and no statistically significant difference was recorded in the artery results. CONCLUSION Responses to osteopathic treatment in women in the third trimester of pregnancy did not affect uteroplacental and fetoplacental circulation. However, some maternal vital signs had statistically significant results, with a decrease in diastolic blood pressure and heart rate, and an increase in systolic blood pressure in the sitting position, a decrease of heart rate in the left lateral decubitus position, and systolic blood pressure in the supine position. All the results observed were maintained in the normal parameters. The study responses attest to the safety of using the osteopathic manipulative treatment for the fetus and for pregnant women with comorbidities.
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French HP, Abbott JH, Galvin R. Adjunctive therapies in addition to land-based exercise therapy for osteoarthritis of the hip or knee. Cochrane Database Syst Rev 2022; 10:CD011915. [PMID: 36250418 PMCID: PMC9574868 DOI: 10.1002/14651858.cd011915.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking. OBJECTIVES To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis. SEARCH METHODS We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE. MAIN RESULTS We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27). AUTHORS' CONCLUSIONS Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.
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Affiliation(s)
- Helen P French
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - J Haxby Abbott
- Orthopaedics: Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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Whatley J, Perkins J, Samuel C. ‘Reflexology: Exploring the mechanism of action’. Complement Ther Clin Pract 2022; 48:101606. [DOI: 10.1016/j.ctcp.2022.101606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/15/2022] [Indexed: 11/25/2022]
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Castagna C, Consorti G, Turinetto M, Lunghi C. Osteopathic Models Integration Radar Plot: A Proposed Framework for Osteopathic Diagnostic Clinical Reasoning. JOURNAL OF CHIROPRACTIC HUMANITIES 2021; 28:49-59. [PMID: 35002577 PMCID: PMC8720649 DOI: 10.1016/j.echu.2021.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 05/24/2023]
Abstract
OBJECTIVE The purpose of this article is to propose a tool to assist with clinical reasoning to select and integrate different osteopathic models and evidence-based actions into clinical practice. DISCUSSION The authors adopted the guidelines for writing a commentary as a reporting framework for the present article. The proposed Osteopathic Models Integration Radar Plot has potential for integration into clinical practice and the educational environment. This framework may enable clinicians to manage complex clinical phenomena, such as musculoskeletal disorders related to allostatic load. CONCLUSION This proposed framework may be helpful to communicate the outcome of osteopathic evaluations to other healthcare professionals. This proposed model will need to be tested to determine feasibility.
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Affiliation(s)
- Carmine Castagna
- Education Department of Osteopathy, Istituto Superiore di Osteopatia, Milan, Italy
| | - Giacomo Consorti
- Education Department of Osteopathy, Istituto Superiore di Osteopatia, Milan, Italy
- Clinical-based Human Research Department, Foundation COME Collaboration, Pescara, Italy
| | - Matteo Turinetto
- Education Department of Osteopathy, Istituto Superiore di Osteopatia, Milan, Italy
| | - Christian Lunghi
- Clinical-based Human Research Department, Foundation COME Collaboration, Pescara, Italy
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Baroni F, Tramontano M, Barsotti N, Chiera M, Lanaro D, Lunghi C. Osteopathic structure/function models renovation for a person-centered approach: a narrative review and integrative hypothesis. JOURNAL OF COMPLEMENTARY & INTEGRATIVE MEDICINE 2021; 0:jcim-2021-0430. [PMID: 34758518 DOI: 10.1515/jcim-2021-0430] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/02/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The construct of the osteopathic structure-function models is reported as a cornerstone of clinical reasoning and treatment processes. Nevertheless, there are no shared procedures described for their use in clinical practice. The present narrative review aims to analyze a more comprehensive perspective on the phenomenon. METHODS A structured narrative review was conducted. A database search was conducted using Pubmed, ScienceDirect, and Google Scholar. Peer-reviewed papers without specifying limits on dates and design were included. RESULTS Twenty-five findings were reported and grouped into two main themes: 1) Debate on models and theoretical frameworks for osteopathic care; 2) Clinical reasoning and decision-making process in the osteopathic field. CONCLUSIONS An integrated osteopathic care approach based on the structure/function models represents a starting point to establish a shared osteopathic diagnostic and clinical reasoning and an evidence-informed practice promoting health in an interdisciplinary person-centered care process. The present review highlights the limited amount of literature on using osteopathic conceptual models in decision-making and treatment strategies. A research plan is required to develop a common framework for an evidence-based osteopathic practice that promotes well-being in an interdisciplinary person-centered care process.
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Affiliation(s)
- Francesca Baroni
- Clinical-Based Human Research Department, Research Division, Foundation COME Collaboration, Pescara, Italy
| | | | - Nicola Barsotti
- Clinical-Based Human Research Department, Research Division, Foundation COME Collaboration, Pescara, Italy
- Research Commission on Manual Therapies and Mind-Body Disciplines, Società Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | - Marco Chiera
- Clinical-Based Human Research Department, Research Division, Foundation COME Collaboration, Pescara, Italy
- Research Commission on Manual Therapies and Mind-Body Disciplines, Società Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | - Diego Lanaro
- Clinical-Based Human Research Department, Research Division, Foundation COME Collaboration, Pescara, Italy
- Research Commission on Manual Therapies and Mind-Body Disciplines, Società Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | - Christian Lunghi
- Clinical-Based Human Research Department, Research Division, Foundation COME Collaboration, Pescara, Italy
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Santiago RJ, Esteves J, Baptista JS, Marques AT, Costa JT. Instrumentation used to assess pain in osteopathic interventions: A critical literature review. INT J OSTEOPATH MED 2020. [DOI: 10.1016/j.ijosm.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Christian L, Torsten L. “Models and theoretical frameworks for osteopathic care – A critical view and call for updates and research”. INT J OSTEOPATH MED 2020. [DOI: 10.1016/j.ijosm.2020.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Kendall JC, Vindigni D, Polus BI, Azari MF, Harman SC. Effects of manual therapies on stability in people with musculoskeletal pain: a systematic review. Chiropr Man Therap 2020; 28:13. [PMID: 32070377 PMCID: PMC7027250 DOI: 10.1186/s12998-020-0300-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 01/21/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction Chronic musculoskeletal pain is associated with reduced balance performance and falls risk. Manual therapies are commonly used interventions for musculoskeletal pain. There is emerging evidence that manual therapies may improve balance. The aim of this systematic review was to examine the effectiveness of manual therapies for musculoskeletal pain on measures of static and dynamic stability. Methods Six electronic databases were searched using pre-defined eligibility criteria and two independent reviewers assessed all identified records. Risk of bias was assessed using the 12-item Cochrane Risk of Bias assessment by two authors independently and any discrepancies resolved through consensus. Meta-analysis was conducted when three or more studies used the same outcome measures including gait speed, timed up and go test, step test and sit-to-stand test. Results Twenty-six studies were included in the analysis. Both spinal and extremity musculoskeletal pain conditions were represented. Manual therapies included manipulation, mobilisation and massage. The most common intervention compared to manual therapy was exercise. Outcome measures included both clinical and objective measures of stability. Overall the risk of bias was reported as generally low or unclear. Conclusion Improvement in stability measures were reported in studies comparing manual therapy in the short term, but not long-term follow-up. There was no clear association between significant pain reduction and measures of stability. Further prospective studies are recommended to investigate whether manual therapies should be part of an integrative healthcare plan for risk of falls management and when a transition from manual therapy to more active interventions should occur for long term management.
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Affiliation(s)
- Julie C Kendall
- Chiropractic, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, 3083, Australia.
| | - Dein Vindigni
- Chiropractic, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, 3083, Australia
| | - Barbara I Polus
- School of Engineering, RMIT University, Bundoora, VIC, 3083, Australia
| | - Michael F Azari
- Chiropractic, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, 3083, Australia.,Private practice, Melbourne, Australia
| | - Samantha C Harman
- Chiropractic, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, 3083, Australia
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Thomaz SR, Teixeira FA, de Lima ACGB, Cipriano Júnior G, Formiga MF, Cahalin LP. Osteopathic manual therapy in heart failure patients: A randomized clinical trial. J Bodyw Mov Ther 2018; 22:293-299. [PMID: 29861222 DOI: 10.1016/j.jbmt.2017.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Heart Failure (HF) patients usually present with increased arterial resistance and reduced blood pressure (BP) leading to an impaired functional capacity. Osteopathic Manual Therapy (OMT) focused on myofascial release techniques (MRT) and in the balancing of diaphragmatic tensions, has been shown to improve blood flow in individuals using the resistive index (RI). However, its effects in HF patients have not been examined. PURPOSE To evaluate the acute response of selected osteopathic techniques on RI, heart rate (HR), and BP in patients with HF. METHODS Randomized-controlled clinical trial of HF patients assigned to MRT (six different techniques with three aimed at the pelvis, two at the thorax, and one at the neck for 15 min) or Control group (subjects in supine position for 15 min without intervention). The RI of the femoral, brachial and carotid arteries was measured via doppler ultrasound while HR and BP were measured via sphygmomanometry before and after a single MRT or control intervention. RESULTS Twenty-two HF patients equally distributed (50% male, mean age 53 years; range 32-69 years) (ejection fraction = 35.6%, VO2peak: 12.9 mL/kg-1 min-1) were evaluated. We found no intra or inter group differences in RI of the carotid (ΔMRT: 0.07% vs Δ Control:11.8%), brachial (ΔMRT:0.17% vs ΔControl: 2.9%), or femoral arteries (ΔMRT:1.65% vs ΔControl: 0.97%) (P > 0.05) and no difference in HR or BP (ΔMRT:0.6% vs ΔControl: 3%), (P > 0.05). CONCLUSION A single MRT session did not significantly change the RI, HR, or BP of HF patients.
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Affiliation(s)
- Sergio R Thomaz
- Sciences and Technologies in Health's Sciences Program, Department of Physical Therapy, University of Brasilia, Brasília, DF, Brazil.
| | - Felipe A Teixeira
- Sciences and Technologies in Health's Sciences Program, Department of Physical Therapy, University of Brasilia, Brasília, DF, Brazil
| | - Alexandra C G B de Lima
- Sciences and Technologies in Health's Sciences Program, Department of Physical Therapy, University of Brasilia, Brasília, DF, Brazil
| | - Gerson Cipriano Júnior
- Physical Education and Rehabilitation Science PhD Program, University of Brasilia, Brasilia, DF, Brazil
| | - Magno F Formiga
- Department of Physical Therapy, Miller School of Medicine, University of Miami, Coral Gables, FL, United States
| | - Lawrence Patrick Cahalin
- Department of Physical Therapy, Miller School of Medicine, University of Miami, Coral Gables, FL, United States
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Anwer S, Alghadir A, Zafar H, Brismée JM. Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis. Physiotherapy 2018; 104:264-276. [PMID: 30030035 DOI: 10.1016/j.physio.2018.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 05/28/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This systematic review to aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and physical performance in patients with knee osteoarthritis (OA). DATA SOURCES Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched. STUDY SELECTION Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or control. DATA EXTRACTION Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC global score, and stairs ascending-descending time. RESULTS Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically insignificant (SDM: -0.59; 95% CI: -1.54 to -0.36; P=0.224). The reduction of VAS score in OMT compared with exercise therapy group was statistically significant (SDM: -0.78; 95% CI: -1.42 to -0.17; P=0.013). The reduction of WOMAC pain score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.79; 95% CI: -1.14 to -0.43; P=0.001). Similarly, the reduction of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.85; 95% CI: -1.20 to -0.50; P=0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically insignificant (SDM: -0.23; 95% CI: -0.54 to -0.09; P=0.164). The reduction of stairs ascending-descending time in OMT compared with the exercise therapy group was statistically significant (SDM: -0.88; 95% CI: -1.48 to -0.29; P=0.004). CONCLUSIONS This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving function, and physical performance in patients with knee OA. REVIEW REGISTRATION PROSPERO 2016:CRD42016032799.
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Affiliation(s)
- Shahnawaz Anwer
- Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.
| | - Ahmad Alghadir
- Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.
| | - Hamayun Zafar
- Rehabilitation Research Chair, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.
| | - Jean-Michel Brismée
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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